What is on my differential diagnosis for a baby who experienced choking and is now asymptomatic?

Differential Diagnosis for a Baby Who Choked and Is Now Asymptomatic

The primary differential diagnosis is a Brief Resolved Unexplained Event (BRUE), but you must systematically rule out retained foreign body aspiration, gastroesophageal reflux with aspiration, swallowing dysfunction, and less commonly, seizure or cardiac arrhythmia. 1

Immediate Diagnostic Considerations

1. Brief Resolved Unexplained Event (BRUE)

• BRUE is diagnosed only after excluding all other causes through thorough history and physical examination in an infant <1 year old 1
• The event must have been brief (<1 minute, typically 20-30 seconds), completely resolved, and included at least one of: cyanosis/pallor, absent/decreased/irregular breathing, marked tone change, or altered responsiveness 1
• Critical exclusion: Events with choking after vomiting or feeding suggest GER and are NOT classified as BRUE 1
• The presence of fever, respiratory symptoms, or nasal congestion would preclude BRUE diagnosis 1

2. Foreign Body Aspiration (Most Critical to Rule Out)

• A history of choking is pathognomonic for foreign body aspiration until proven otherwise, even if the child appears asymptomatic now 2
• The aspiration event may have been unwitnessed, so absence of clear history does not exclude it 2
• A normal chest X-ray does NOT exclude foreign body aspiration—clinical history takes precedence 2
• If the child was witnessed choking while having small particles in their mouth, prompt evaluation is mandatory regardless of current symptom status 2
• Never perform blind finger sweeps as they may push foreign bodies further into the airway 1, 3, 2

3. Gastroesophageal Reflux (GER) with Aspiration

• Events characterized as choking after vomiting strongly indicate GER as the etiology 1
• GER can present with respiratory symptoms including wheezing and apparent choking episodes 1
• Swallowing dysfunction with aspiration occurs in approximately 12-13% of infants with respiratory symptoms 1
• Among infants with swallowing dysfunction, 70% have tracheal aspiration and 30% have laryngeal penetration 1

4. Swallowing Dysfunction/Dysphagia

• Video-fluoroscopic swallowing studies identify aspiration in 12-13% of infants <1 year with respiratory symptoms or vomiting 1
• Coordination of swallowing improves with age, and dysfunction often resolves within 3-9 months with appropriate management 1
• Consider this especially if there is a history of feeding difficulties or recurrent "choking" episodes 1

5. Ingested (Not Aspirated) Foreign Body

• If the object was swallowed rather than aspirated, obtain an abdominal X-ray to confirm presence, location, and number of objects 3
• Maintain normal diet and hydration in asymptomatic children with the object in the stomach or beyond 3
• Do not give laxatives or induce vomiting—this does not accelerate passage and may cause complications 3

6. Less Common but Important Differentials

Seizure Activity

• Assess for tonic eye deviation, nystagmus, tonic-clonic movements, or infantile spasms during the event 1
• Post-ictal phase may have been mistaken for resolution of choking episode 1

Cardiac Arrhythmia/Long QT Syndrome

• Obtain family history of sudden unexplained death in first- or second-degree relatives before age 35, particularly in infancy 1
• Ask about family history of long QT syndrome or arrhythmias 1

Breath-Holding Spell

• These are benign events that can be distinguished from more serious pathology by characteristic history 1

Non-Accidental Trauma

• Always consider: Multiple or changing versions of history, history inconsistent with developmental stage, unexplained bruising 1

Critical Historical Features to Elicit

Event Characteristics:

• Was there choking or gagging noise during the event? 1
• Was the infant feeding, or was anything in the mouth? 1
• Were objects nearby that could be aspirated or swallowed? 1
• What was the infant's position (supine, prone, upright)? 1
• How did the event resolve—spontaneously or with intervention (back blows, picking up, positioning)? 1

Duration and Resolution:

• Approximate duration of the event 1
• Did it end abruptly or gradually? 1
• Was the infant back to baseline immediately or gradually? 1

Immediate Management Approach

1. If foreign body aspiration is suspected based on witnessed choking with small objects, proceed directly to imaging and possible bronchoscopy 2
2. For ingested foreign bodies, obtain abdominal X-ray as first-line imaging 3
3. Watch for red flags requiring immediate intervention: persistent vomiting, severe abdominal pain, respiratory distress, signs of perforation, or hematemesis 3
4. If BRUE is suspected, stratify risk and determine need for admission versus outpatient monitoring 1

Common Pitfalls to Avoid

• Do not be falsely reassured by normal radiographs when clinical history suggests foreign body aspiration 2
• Do not classify an event as BRUE if there was vomiting or feeding-related choking—this suggests GER 1
• Do not perform blind finger sweeps 1, 3, 2
• Do not use barium contrast studies for suspected foreign bodies—they can coat the object and increase aspiration risk 3